See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/273066274

Supraventricular tachycardia after nebulized salbutamol therapy in a neonate:

Case report

Article  in  Archivos Argentinos de Pediatría · April 2015

DOI: 10.1590/S0325-00752015000200018 · Source: PubMed

CITATIONS READS

4 1,170

5 authors, including:

Birgul Say Halil Degirmencioglu

Dr. Zekai Tahir Burak Women's Health Research and Education Hospital Dr. Zekai Tahir Burak Women's Health Research and Education Hospital
12 PUBLICATIONS   69 CITATIONS    32 PUBLICATIONS   341 CITATIONS   

SEE PROFILE SEE PROFILE

Gozde Hayriye Kutman Nurdan Uras

Dr. Zekai Tahir Burak Women's Health Research and Education Hospital 229 PUBLICATIONS   2,636 CITATIONS   
68 PUBLICATIONS   432 CITATIONS   
SEE PROFILE
SEE PROFILE

Some of the authors of this publication are also working on these related projects:

case report View project

Zekai Tahir Burak Women’s Health Education and Research Hospital newborn hearing screening results and assessment of the patients View project

All content following this page was uploaded by Birgul Say on 30 July 2018.

The user has requested enhancement of the downloaded file.

Case report
Supraventricular tachycardia after nebulized salbutamol
therapy in a neonate: Case report
Birgul Say MDa, Halil Degirmencioglu MDa, Hayriye Gozde Kanmaz Kutman MDa, Nurdan Uras MDa and
Ugur Dilmen MDa,b
ABSTRACT
Supraventricular tachycardia (SVT) is the most common
sustained arrhythmia in neonates and infants. Presentation of
SVT in the neonate is usually subtle and frequently complicated
by congestive heart failure. Despite the widespread use of
β2-agonists, their safety has been questioned. Several studies
have reported an increased incidence of cardiac arrhythmias in
patients treated with these agents, and other studies have found
increased rates of cardiovascular death associated with the use
of oral and nebulized β2-agonists such as salbutamol, which is
used to treat bronchospasm in newborns with several diseases.
Herein, we report a case of SVT following administration of
nebulized salbutamol in a neonate.
Keywords: tachycardia supraventricular, salbutamol, newborn.
http://dx.doi.org/10.5546/aap.2015.eng.e98
INTRODUCTION
Supraventricular tachycardia (SVT) includes
all forms of tachycardia originated above
the bifurcation of the bundle of His or have
mechanisms dependent on the bundle of His.
SVT is the most common sustained arrhythmia
in neonates and infants. Predisposing factors such
as congenital heart disease, drug administration,
illness, and fever occur only in 15% of cases.1 The
presentation of SVT in the neonate is frequently
subtle and it may include pallor, cyanosis,
restlessness, irritability, feeding difficulty,
tachypnea, diaphoresis and grunting. SVT in
newborns is frequently complicated by congestive
heart failure, characterized by a fixed heart
rate usually greater than 230 beats per minute.
Typical electrocardiogram (ECG) findings of
SVT include narrow QRS complexes, regular R-R
a. Division of Neonatology, Zekai Tahir Burak Maternity
Teaching Hospital.
b. Department of Pediatrics, Yıldırım Beyazıt University
School of Medicine
Ankara,Turkey.
E-mail Address:
Halil Degirmencioglu MD: hdegirmencioglu@gmail.com
Conflict of Interest: None.
Received: 7-14-2014
Accepted: 11-3-2014
Arch Argent Pediatr 2015;113(2):e98-e100 / e98
intervals, and absent P waves or an abnormal P
wave axis. Salbutamol, which has been used as
bronchodilators for the prevention and treatment
of chronic lung disease in preterm infants, for
emergency treatment of hyperkalemia, and
transient tachypnea of the newborn (TTN),2-4 is a
direct-acting sympathomimetic agent that has a
selective β-adrenergic effect. Because β-receptors
in the heart are mainly the β-1 type, it is believed
that salbutamol has minimal cardiovascular
effects; however, tachycardia and cardiac
arrhythmias have been reported as complications
of salbutamol administration. 5 Although well
documented in adults, cardiac arrhythmias have
not been widely reported in pediatric patients as
a complication of salbutamol therapy.
This paper presents the case of an infant who
was admitted to the neonatal intensive care unit
(NICU) with a diagnosis of meconium aspiration
syndrome and who developed multiple SVTs
following administration of salbutamol during
the recovery phase of her underlying illness.
CASE REPORT
The patient was a girl born to a 28-year-old
mother via a spontaneous vaginal delivery after
a term gestation; the birth weight was 3600 g.
The mother was healthy and had an uneventful
pregnancy. The baby was delivered through thick
meconium and she was cyanotic. Her mouth was
suctioned and she was intubated and suctioned
for thick, particulate meconium. Her pulse fell
below 100 beats per minute (bpm) and positive-
pressure ventilation (PPV) was initiated. The
patient’s first and fifth Apgar scores were 5 and 6,
respectively and she was transferred to the NICU.
On admission to the NICU, the infant had a pulse
of 157 (bpm), a respiration rate of 72 per minute,
and a mean arterial blood pressure of 34 mmHg.
She remained with 100% oxygen. A capillary
blood gas test showed a pH of 7.31, a PCO 2 of
43 mmHg, and a SpO 2 of 94% at 20 minutes
of life, and she was severely tachypneic. After
intubation, a blood culture was taken, a sepsis
evaluation was performed, and intravenous
(IV) antibiotics (crystalline penicilline; 50,000

units/kg/day in divided doses every 12 hours,
and gentamicine 4 mg/kg/day every 24 hours)
were begun. Chest radiography revealed
dense bilateral infiltrates with prominent air
bronchograms. An echocardiogram at 10 hours of
life revealed septal hypertrophy with flattening of
the ventricular septum, consistent with persistent
pulmonary hypertension of the neonate (PPHN).
Treatment was aimed at interrupting the cycle
of pulmonary vasoconstriction and hypoxia.
Her chest radiographs started to demonstrate a
reticulogranular pattern, and there was concern
that she might have an element of surfactant
deficiency.
Over the next several days, the need to
ventilate and oxygenate the patient gradually
decreased, and on day 7 of life, she was extubated
to a nasal cannula. She had coarse bilateral breath
sounds with marked expiratory wheezing. The
cardiovascular examination was unremarkable,
the echocardiographic examination was normal,
and serum potassium and the other electrolytes
were in the normal ranges at this time. Inhaled
salbutamol therapy was initiated at a dose of
0.15 mg/kg (0.45mg) every 4 hours. Following
the inhalation of salbutamol solution (Ventolin
nebules® 50, Glaxo Wellcome; Greenford, UK),
the infant’s heart rate increased suddenly to
314 bpm. The ECG showed a narrow complex
tachycardia at a heart rate of 310 bpm and
retrograde conducted P waves buried in the ST
segment at an RP interval (Figure 1). Adenosine
was administered via IV rapid bolus at a dose of
100 mcg/kg which was repeated twice. However,
we were not able to obtain sinus rhythm
despite the raised dose for the two subsequent
Figure 1. Electrocardiogram indicative of supraventricular
tachycardia, with no visible P wave and normal QRS
morphology.
Case report / Arch Argent Pediatr 2015;113(2):e98-e100 / e99
administrations of adenosine treatment and
electrical cardioversion was performed, which
terminated the SVT. Salbutamol treatment was
ceased and SVT was never observed again. The
patient was doing well and was discharged from
the hospital on day 15 of life.
DISCUSSION
Despite the widespread use of β2-agonists,
their safety has been questioned. Existing data
on the effects of these agents, especially those
administered in an inhaled form, on myocardial
electrophysiological properties are rare. 6
Pharmacologically, however, inhaled salbutamol
can result in significant changes in cardiac
electrophysiological properties.6 Salbutamol has
been found to enhance atrioventricular nodal
conduction and to decrease atrioventricular nodal,
atrial, and ventricular refractoriness in addition to
its positive chronotropic effects. b2-agonists also
increase QT dispersion. All of these alterations
theoretically could contribute to the generation
of tachycardia and tachyarrhythmias. Several
studies have reported an increased incidence
of cardiac arrhythmias in patients treated with
the use of oral and nebulized β2-agonists. 5-7
A recent human study demonstrated that
salbutamol, a selective β2-agonist, administered
by nebulizer has significant electrophysiological
effects on the atrium, nodes, and ventricle.
Some studies found that salbutamol produced
more evident changes on the electrophysiologic
properties of the sinus node compared with
the atrioventricular node.6,8 The cardiac effects
of β2-agonists include tachycardia, atrial and
ventricular ectopic complexes, and atrial and
ventricular arrhythmias.6,9
Although adverse drug reactions including
tremor (90%), hypokalaemia (45.5%), and
supraventricular tachycardia (21%) were reported
to be common, especially after administration of
continuous intravenous infusion of salbutamol,10
the estimated SVT rate in children treated
with inhaled β2-agonists remains unknown.
Tachycardia and tachyarrhythmias are very
common in critically ill adult patients with
various conditions. 11 Predisposing factors for
SVT include congenital heart disease, fever, and
sympathomimetics.8,12 Our patient had no history
of congenital heart disease or fever. Although
she required brief PPV in the delivery room and
respiratory support and she suffered from mild
PPHN, her myocardial functions and cardiac
output were always within normal limits, and
 e100 / Arch Argent Pediatr 2015;113(2):e98-e100 / Case report
no signs were observed of myocardial ischemia,
which could cause a tendency toward arrhythmia.
Acute management of SVT in children involves
the use of vagal maneuvers or IV adenosine. IV
adenosine has been found to be safe and highly
effective in the management of SVT in infants and
children.5
Two previous patient reports have described
salbutamol-induced SVT in children. In the
first report, SVT in a 19-month-old baby was
converted by applying facial ice, and in the
second case, a 4-year-old patient recovered with
IV adenosine. 5,6 We initially administered a
100 mcg/kg dose of IV adenosine, and despite
two repeated doses of 200 mcg/kg, we could
not obtain sinus rhythm. Cardioversion was
performed with 2j/kg followed by 4j/kg, and this
treatment was successful.
Although nebulized, short-acting β2-agonists
are effective bronchodilator drugs that are widely
prescribed for the treatment of airflow obstruction
and increasingly for TTN and hyperkalemia in
NICUs, there is considerable concern about their
potential side effects, particularly those pertaining
to heart rate and arrhythmias. In addition, β2
agonists are widely used to treat neonates with
bronchopulmonary dysplasia, but there is no
evidence of their efficacy.
Therefore, we suggest that all infants should
be carefully monitored for tachycardia which
requires urgent treatment after nebulized
salbutamol in both ambulatory and inpatient
care, even if there are no underlying causes.
Underlying causes that might facilitate
arrhythmia should be evaluated.n
View publication stats
REFERENCES
1. Moak JP. Supraventricular tachycardia in the neonate and
infant. Prog Pediatr Cardiol 2000;11(81):25-38.
2. Armangil D, Yurdakök M, Korkmaz A, Yigit S, et al. Inhaled
beta-2 agonist salbutamol for the treatment of transient
tachypnea of the newborn. J Pediatr 2011;159(3):398-403.
3. Ng G, da Silva O, Ohlsson A. Bronchodilators for the
prevention and treatment of chronic lung disease in preterm
infants. Cochrane Database Syst Rev 2012;6:CD003214.
4. Vemgal P, Ohlsson A. Interventions for non-oliguric
hyperkalaemia in preterm neonates. Cochrane Database
Syst Rev 2012;5:CD005257.
5. Duane M, Chandran L, Morelli PJ. Recurrent supraventricular
tachycardia as a complication of nebulized albuterol
treatment. Clin Pediatr (Phila) 2000;39(11):673-7.
6. Kallergis EM, Manios EG, Kanoupakis EM, Schiza SE, et
al. Acute electrophysiologic effects of inhaled salbutamol
in humans. Chest 2005;127(6):2057-63.
7. Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular
effects of b-agonists in patients with asthma and COPD:
a meta-analysis. Chest 2004;125(6):2309-21.
8. Lowe MD, Rowland E, Brown MJ, Grace AA. Beta(2)
adrenergic receptors mediate important electrophysiological
effects in human ventricular myocardium. Heart
2001;86(1):45-51.
9. Keller KA, Bhisitkul DM. Supraventricular tachycardia:
a complication of nebulized albuterol. Pediatr Emerg Care
1995;11(2):98-9.
10. Habashy D, Lam LT, Browne GJ. The administration
of beta2-agonists for paediatric asthma and its adverse
reaction in Australian and New Zealand emergency
departments: a cross-sectional survey. Eur J Emerg Med
2003;10(3):219-24.
11. Khorfan FM, Smith P, Watt S, Barber KR. Effects of nebulized
bronchodilator therapy on heart rate and arrhythmias in
critically ill adult patients. Chest 2011;140(6):1466-72.
12. Flatt A, Crane J, Purdie G, Kwong T, et al. The cardiovascular
effects of beta adrenergic agonist drugs administered by
nebulisation. Postgrad Med J 1990;66(772):98-101.